P - 40702Building
Inspections
763-572-3604
763-502-4977 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-I-2011
Permit No.:
Received By: �-
D�� � � `�0��
� `r '`��' � M
��i DATE_ ;�'�'J �'� 2� � 2�'j // YOUR E-MAIL ADDRESS G" G:�� E�'I GL�t ur �i h. ecr J' c v=�
SITE ADDRESS f'�, [? 1� l 3� 3 �`7 k� S c C� � j,� (�.' l,' �{ ,
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/
TENANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CERTIFICATE OF
INSURANCE
PROPERTY TYPE
PERMIT TYPE
TYPE OF WORK:
NAME: /��-' ���
ADDRESS: �j f���� j� lt„�;{� u CITY %'�'} / dty�tr.�,�U �/S STATE�ZjIz✓ ZIP
PHONE: iQf 2-��'( ~ 1 3�-1 d
STATE LICENSE # t�(,(�(7 �-/ � y LEAD CERT NUMBER
ADDRESS:�S` � Z ��Sf' /tt/� CiTY ST ���.+.�1 STATF�jLIP ��$�10�,
PHONE CvS (— G(rrp �7�'� FAX
❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
�WO FAMILY ION STORIES
❑ ADDITION ❑ GARAGE/SHED ❑ WINDOWS
❑ BASEMENT FINISH �,�-ROOF ❑ DRAIN TILE
O DECK ❑ SIDING ❑ OTHER
❑ SWIMMING POOL
�❑ EW HOME CONSTRUCTION ❑ ADDITION
AINTENANCE/REPAIR ❑ REMODELING
DESCRIBE WORK BEING DONE:
WIDTH
ROOFTNG
NUMBER OF SQUARES��r�
GARAGES
PROPOSED SIZE:
PROPOSED HEIGHT:
SIDING
❑ Vinyl
❑ Aluminum
❑ Other
�i•IOUSE ONLY
❑ HOUSE & GARAGE
❑ ATTACHED GARAGE
❑ DETACHED GARAGE
❑Soffit
❑ Trim
❑ Fascia
WINDOWS
IN EXISTING OPENINGS ❑Yes ONo LOCATION OF WINDOWS
OR FOR NEW OPENINGS-DESCRIBE SIZE OF
OPENING CHANGES &
.� �
BASEMENT REMODELING SUBMIT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
FOR NEW CONSTRUCTION fNCLUDING DECKS,
ADDITIONS. & PORCHES SUBMIT:
1. Site Plan/Survey showing the existing structures
and proposed project.
2. Two sets of construction plans
3. Energy Calculations
FOR WINDOWS — PROVIDE U-VALUE AND
MANUFACTURE STICKER ON WINDOW.
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS �
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
TOTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
Plan Review
Fire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
Erosion Contro]
Park Fee
Sewer Main Charge
Total Due
$ �'y ��S
$
$ �:
$
$ ��
$
$
$
$ �)1 :"J�1 '
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary (
Make checks pavable to: Citv of Fridlev
Attach Stipulations
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNT[L PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work wili be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case o a rk wh� uires review and approval of pla �/ �j, C- 7�
SIGNATURE OF APPLICANT PRINT NAME � 7U�c3 l l'� Q''� DATE J�'�l- Z�`Z� I(
APPROVAL INSPECTOR SIGNAT E